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       Florida Senate - 2010                                    SB 1132
       By Senator Sobel
       31-00797A-10                                          20101132__
    1                        A bill to be entitled                      
    2         An act relating to antiretroviral drugs; amending ss.
    3         409.912 and 627.6265, F.S.; prohibiting limitations on
    4         the prescribing of antiretroviral drugs for treating
    5         human immunodeficiency virus infection; amending s.
    6         627.6515, F.S.; conforming provisions to changes made
    7         by the act; creating ss. 627.65736 and 641.31093,
    8         F.S.; prohibiting health insurance policies and health
    9         maintenance organizations from limiting the
   10         prescribing of antiretroviral drugs for treating human
   11         immunodeficiency virus infection; providing an
   12         effective date.
   14  Be It Enacted by the Legislature of the State of Florida:
   16         Section 1. Subsection (54) is added to section 409.912,
   17  Florida Statutes, to read:
   18         409.912 Cost-effective purchasing of health care.—The
   19  agency shall purchase goods and services for Medicaid recipients
   20  in the most cost-effective manner consistent with the delivery
   21  of quality medical care. To ensure that medical services are
   22  effectively utilized, the agency may, in any case, require a
   23  confirmation or second physician’s opinion of the correct
   24  diagnosis for purposes of authorizing future services under the
   25  Medicaid program. This section does not restrict access to
   26  emergency services or poststabilization care services as defined
   27  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   28  shall be rendered in a manner approved by the agency. The agency
   29  shall maximize the use of prepaid per capita and prepaid
   30  aggregate fixed-sum basis services when appropriate and other
   31  alternative service delivery and reimbursement methodologies,
   32  including competitive bidding pursuant to s. 287.057, designed
   33  to facilitate the cost-effective purchase of a case-managed
   34  continuum of care. The agency shall also require providers to
   35  minimize the exposure of recipients to the need for acute
   36  inpatient, custodial, and other institutional care and the
   37  inappropriate or unnecessary use of high-cost services. The
   38  agency shall contract with a vendor to monitor and evaluate the
   39  clinical practice patterns of providers in order to identify
   40  trends that are outside the normal practice patterns of a
   41  provider’s professional peers or the national guidelines of a
   42  provider’s professional association. The vendor must be able to
   43  provide information and counseling to a provider whose practice
   44  patterns are outside the norms, in consultation with the agency,
   45  to improve patient care and reduce inappropriate utilization.
   46  The agency may mandate prior authorization, drug therapy
   47  management, or disease management participation for certain
   48  populations of Medicaid beneficiaries, certain drug classes, or
   49  particular drugs to prevent fraud, abuse, overuse, and possible
   50  dangerous drug interactions. The Pharmaceutical and Therapeutics
   51  Committee shall make recommendations to the agency on drugs for
   52  which prior authorization is required. The agency shall inform
   53  the Pharmaceutical and Therapeutics Committee of its decisions
   54  regarding drugs subject to prior authorization. The agency is
   55  authorized to limit the entities it contracts with or enrolls as
   56  Medicaid providers by developing a provider network through
   57  provider credentialing. The agency may competitively bid single
   58  source-provider contracts if procurement of goods or services
   59  results in demonstrated cost savings to the state without
   60  limiting access to care. The agency may limit its network based
   61  on the assessment of beneficiary access to care, provider
   62  availability, provider quality standards, time and distance
   63  standards for access to care, the cultural competence of the
   64  provider network, demographic characteristics of Medicaid
   65  beneficiaries, practice and provider-to-beneficiary standards,
   66  appointment wait times, beneficiary use of services, provider
   67  turnover, provider profiling, provider licensure history,
   68  previous program integrity investigations and findings, peer
   69  review, provider Medicaid policy and billing compliance records,
   70  clinical and medical record audits, and other factors. Providers
   71  shall not be entitled to enrollment in the Medicaid provider
   72  network. The agency shall determine instances in which allowing
   73  Medicaid beneficiaries to purchase durable medical equipment and
   74  other goods is less expensive to the Medicaid program than long
   75  term rental of the equipment or goods. The agency may establish
   76  rules to facilitate purchases in lieu of long-term rentals in
   77  order to protect against fraud and abuse in the Medicaid program
   78  as defined in s. 409.913. The agency may seek federal waivers
   79  necessary to administer these policies.
   80         (54) Notwithstanding any other provision of this section,
   81  antiretroviral drugs prescribed to treat human immunodeficiency
   82  virus infection must be included on a provider’s formulary and
   83  may not be restricted through a requirement for prior
   84  authorization, a step-therapy approval process, or other
   85  limitation that restricts access to antiretroviral drugs.
   86         Section 2. Section 627.6265, Florida Statutes, is amended
   87  to read:
   88         627.6265 HIV infection Cancellation or nonrenewal
   89  prohibited.—
   90         (1) Notwithstanding any other provision of law to the
   91  contrary, an no insurer may not shall cancel or nonrenew the
   92  health insurance policy of an any insured because of diagnosis
   93  or treatment of human immunodeficiency virus infection or
   94  acquired immune deficiency syndrome.
   95         (2) Antiretroviral drugs prescribed to treat the human
   96  immunodeficiency virus infection of an insured must be included
   97  on a health plan formulary and may not be restricted through a
   98  requirement for prior authorization, a step-therapy approval
   99  process, or other limitation that restricts access to
  100  antiretroviral drugs.
  101         Section 3. Paragraph (c) of subsection (2) of section
  102  627.6515, Florida Statutes, is amended to read:
  103         627.6515 Out-of-state groups.—
  104         (2) Except as otherwise provided in this part, this part
  105  does not apply to a group health insurance policy issued or
  106  delivered outside this state under which a resident of this
  107  state is provided coverage if:
  108         (c) The policy provides the benefits specified in ss.
  109  627.419, 627.65736, 627.6574, 627.6575, 627.6579, 627.6612,
  110  627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and
  111  627.66911.
  112         Section 4. Section 627.65736, Florida Statutes, is created
  113  to read:
  114         627.65736 HIV infection.Antiretroviral drugs prescribed to
  115  treat the human immunodeficiency virus infection of an insured
  116  must be included on a health plan formulary and may not be
  117  restricted through a requirement for prior authorization, a
  118  step-therapy approval process, or other limitation that
  119  restricts access to antiretroviral drugs.
  120         Section 5. Section 641.31093, Florida Statutes, is created
  121  to read:
  122         641.31093HIV infection.—Antiretroviral drugs prescribed to
  123  treat the human immunodeficiency virus infection of a subscriber
  124  must be included on a health plan formulary and may not be
  125  restricted through a requirement for prior authorization, a
  126  step-therapy approval process, or other limitation that
  127  restricts access to antiretroviral drugs.
  128         Section 6. This act shall take effect July 1, 2010.

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